Healthcare Reform’s Wild Week – What Happened?

Once again, – as we have stated before – Republican efforts to repeal the Affordable Care Act failed last week, and the GOP will move on to other legislation. It all came down to Senator John McCain (R-Ariz.), returning to the Senate floor following the diagnosis of a brain tumor – joining his Republican colleagues Lisa Murkowski (R-AK) and Susan Collins (R-ME) in opposing the bill in a dramatic late night fashion. But the events leading up are just as theatrical and provide context to the state of healthcare reform in the United States. Here is a day-by-day recap of the events leading up to, and including the final vote on ACA repeal.

Tuesday, July 25th

Senate Majority Leader Mitch McConnell held a procedural vote to begin debate on an ACA repeal bill (McConnell left it vague as to what the bill the Senate was considering), which passed with 50 votes plus Vice President Mike Pence’s tie-breaking vote. To boost support for the bill, McConnell turned to John McCain who had just returned to the senate following his recovery to remove a blood clot and a brain cancer diagnosis. After casting his vote to move forward, McCain delivered a speech criticizing the secretive process of the bill, declaring his lack of support for the bill, and urging his fellow Senators to restore “regular order” of passing legislation with a 60-vote majority.

Following this, the Senate voted down the bill similar to the version outlined here but with an additional $100 billion to cover people’s transition off Medicaid with only 43 votes, including McCain.

Wednesday, July 26th

Today, the Senate voted on the “Obamacare Repeal Reconciliation Act,” which was labeled as a “repeal, no replace” bill (the bill only repealed budgetary items that could be approved by a simple majority) in order to meet an obligation to secure Senator Rand Paul’s (R-Ky.) yes vote from the day before. While it was clear the bill did not have enough votes to pass, some saw it as McConnell’s plan to get his fellow Senate Republicans (who campaigned on repealing the ACA) to go on record voting against a repeal. The bill did not pass with only 45 votes.

Thursday, July 27th

When it became apparent that the neither of the previous efforts to repeal would work, rumors began to spread of a so-called “skinny repeal.” The goal of the “skinny repeal” was to remove all of the past provisions that were causing trouble and only focus on repealing the core provisions that all Republican’s disliked: The individual mandate, the employer mandate, and the medical device tax. By Thursday morning, this became the only viable option for McConnell.

By Thursday evening, however, the way forward encountered yet another roadblock. Senators Lindsay Graham (R-S.C.), Ron Johnson (R-Wis.) and John McCain held a press conference proclaiming they would not support the “skinny repeal” unless they received assurances from Speaker of the House Paul Ryan that the House would work with the Senate to create a compromise bill that would garner the votes necessary in both chambers. Shortly after 8 pm, Speaker Ryan announced the house was “willing” to conference on the bill, and after a call between the Senators and the Speaker Graham and Johnson walked away convinced, but McCain was still uncertain.

Then, just before 11 pm on Thursday, hours before the vote, the Senate released the text of the “skinny” bill dubbed the Health Care Freedom Act. The bill included the following provisions:

A repeal of the individual mandate

A repeal of the employer mandate through 2024

A postponement of the medical device tax

Cutting off federal funds for Planned Parenthood

Expansion of the ACA waiver program, allowing states the option to roll back ACA benefit mandates

Expanding HSA funding

Friday, July 28th

The Congressional Budget Office releases a budget score for the Health Care Freedom Act. The report indicated the bill would result in 16 million fewer insured by 2026 and a 20 percent increase in premiums. The bill would save $135 billion over 10 years, which is significant because it matched the savings generated by the House-approved AHCA and thus can be passed with 51 votes in the Senate.

Early in the morning, the voting began. Vice President Mike Pence arrived on the Senate floor, expecting he would cast the tie breaking vote – Senators Collins and Murkowski tie-breaking as hard no’s and the bill would pass with 50 votes and could lose no more.

It became clear very quickly that something was amiss. Rather than standing at the podium, Mike Pence was seen standing next to McCain, encouraging him to shift his vote. As the roll call began, the Republicans fell in line, voting “yes”. When it became McCain’s turn, he voted “no” and gave a thumbs down to an audible gasp from his colleagues.

After the failure, McConnell gave an address expressing disappointment and blaming Democrats for it. President Trump tweeted his commitment to letting the ACA “implode.”

What Happens Next?

It is expected, as it has been every time the bill has seemed to fail, that Congress will move on to tax reform, but that doesn’t mean healthcare reform will be gone for good. Some moderate Republicans have expressed interest working on a bipartisan bill to help the individual market. A group of 40 Representatives from both side of the aisle, calling themselves the Problems Solvers Caucus, has already been meeting to discuss fixes to the ACA. It is unclear if President Trump would veto such an effort.

Also to look out for is how the Trump administration would enforce a law it despises. Will the IRS enforce the individual and employer mandates? Will the administration continue to subsidize insurance purchased through a marketplace? Will the regulatory agencies roll back guidance on the ACA? Will the future tax reform efforts target specific taxes generated by the ACA?

These remain unanswered, but we do know that the ACA is here to stay – at least for now. It is crucial that, until things change, to remain vigilant and on top of all ACA provisions in order to avoid potential fines and litigation. The Certified Healthcare Reform Specialist® designation is here to help you stay on top of these developments.